Julie Appleby of Kaiser Health News has an intriguing story about five insurers in Oregon offering "value-based insurance design."

She explains:

"...a new type of insurance that offers free care for some illnesses, such as diabetes or depression, but requires hefty extra fees for treatments deemed overused, including knee replacements, hysterectomies and heart bypass surgery.
...

The policies are among the first to apply financial incentives on both sides of one important factor driving up the nation's health care tab: The underuse of proven treatments and overuse of certain surgeries and diagnostic tests that may be less valuable."

The Center for Public Integrity has posted a searchable database of what they say are the 1,750 companies and organizations that have hired 4,525 lobbyists to influence health care reform legislation. The Center states:

"Despite the recession, 2009 was a boom year for influence peddling overall with business and advocacy groups shelling out $3.47 billion for lobbyists to represent them on all kinds of issues, according to the nonprofit group Center for Responsive Politics.

Much of that money went to fight the health reform battle, according to Center for Public Integrity data. Businesses and organizations that lobbied on health reform spent more than $1.2 billion on their overall lobby efforts. The exact amount they spent on health reform is difficult to quantify because most health care lobbyists also worked on other issues, and lobby disclosure rules do not require businesses to report how much they paid on each issue.

From an industry perspective, it was money well spent. A close look at the health reform bills that passed the House and Senate show lobbyists were apparently effective at blocking provisions like a robust government-run insurance program, and blunting the effect of cost-cutting measures on health care companies."

WBBM in Chicago last week asked, "Is Medicare Ignoring Cheaper Lung Cancer Test?"

In its report, the TV station's "investigator" team promoted a company president's complaints against Medicare for much of the piece. They let him get away with saying:

"This is a potentially very powerful tool in the toolbox against lung cancer. You can zap the cancer and potentially be cured of early-stage lung cancer without ever having the surgery."

Should we be hearing that from a company president worried about his bottom line while he "wows" the audience with blown-up images like the one at left that appeared in the story? Or should we hear about evidence and data from an independent investigator whose research could speak to efficacy? The story never provided any data to back up the company president's self-interested claims.

They also let him get away with saying, "I think it has the potential to save Medicare millions of dollars."

We're not getting much smarter from stories like this. We're sure not getting a better understanding that in health care, "more is not always better and newer is not always better." We're also not being shown how often special interests - Pharma, device makers, specialty physician groups, etc. - are digging in against health care reform.

Recently, Trudy Lieberman wrote in the Columbia Journalism Review about how cardiologists were using journalists to complain about their reimbursement levels being cut by Medicare. She wrote:

"The doctors' letter warned that they "will be either forced out of business or forced to drastically increase the number of patients seen, most likely with physician assistants or nurse practitioners." Oh, oh. The specter of rationing and inferior care--"

See the similar themes in what she wrote about and in what we saw in the Chicago WBBM story?

Lieberman praised a Miami Herald story for how it handled the issue but said that:

"..a bunch of news articles for the most part passed along the cardiologists' complaints, threats, and warnings without any hint that there was another side to the story. Between the slanted newspaper articles and audio news releases from the American College of Cardiology, millions of Americans learned that the incomes of heart doctors, which can be upwards of $400,000, could take a hit. As an example of the kinds of cuts Medicare envisioned under the new rule, the administrator of one Florida heart practice explained that the reimbursement for a nuclear stress test could drop from $850 to $600. Presumably he said it with a straight face."

News stories that foster rhetoric and fear-mongering aren't making us any smarter. As Lieberman wrote:

"Containing the runaway cost of medical care is the thorniest of all the thorny issues in the health-reform debate. It is a complicated, charged, and crucial issue; the press needs to dig in and own it."

The health spendings projection article in Health Affairs contains this one historic note:

In 2009 the health share of gross domestic product (GDP) is expected to have increased 1.1 percentage points to 17.3 percent--the largest single-year increase since 1960.

A Los Angeles Times story gets to the heart of the matter:

"There is growing concern that as much as a third of the medical care delivered in this country does not help patients.

"Are we getting value for the dollar? That is the question," said Len Nichols, health policy director at the centrist New America Foundation. "If you believe that so much medical care is unnecessary, as I do, then it is criminal that we are spending so much."

Yet there is gridlock on federal health care reform legislation. Indeed, for all the rhetoric and fear-mongering about "government taking over health care," the latest data shows we're already there.

The Wall Street Journal reports and provides this graphic:

"For the first time, government programs next year will account for more than half of all U.S. health-care spending, federal actuaries predict, as the weak economy sends more people into Medicaid and slows growth of private insurance."

One of the reasons we review news stories about "new stuff" in health care is that we believe news stories may drive up undue demand for unproven, perhaps unsafe, and costly new technologies without giving a balanced picture of the tradeoffs between harms and benefits, without evaluating the quality of evidence behind the new ideas, without looking at conflicts of interest in those promoting the new ideas, etc.

At last check, 70% of the nearly 1,000 stories we've reviewed fail to adequately discuss costs, or quantify harms or benefits. A kid-in-the-candy-store view of US health care.

We believe these are health care reform stories - even though they often aren't presented that way. Just look at what we've written about just in the past week and you see the daily drumbeat of news stories and ads that fill our heads with visions of sugar plums in health care.

• CT and MRI scans

• Robotic surgery

• A weeklong network TV series taking you inside the O.R. for technological wonders

• Misleading drug ads

17.3% of the GDP and rising.

A team of reporters from KHN delivers this thoughtful piece. Excerpts:

"There's nothing in (the proposals) the average person could understand about why your costs would be lower," says Robert Blendon, professor of health policy at Harvard's School of Public Health. "They don't even have good illustrations about how it would be cheaper. They did not find a way to save money for people with job-based insurance." ...

Many of the taxes have been dropped or scaled back. Others have been designed to pressure the health care system to operate more efficiently. But the laundry list of levies has fueled concerns that Americans, struggling with the severest economic slump in decades, would have to pony up more for the tax man.

"The final bill will not have all those taxes in it," says Blendon, "but people hear about the tax on insurers, the tax on pharmaceuticals, the income tax - and they can't segregate it in their minds." Opposition to taxes was a key part of (newly-elected Massachusetts Senator Scott ) Brown's campaign.

"People don't like taxes," says Leslie Norwalk, who was acting director of the Centers for Medicare and Medicaid during the administration of President George W. Bush. "The electorate is trying to decide what it thinks about this health care stuff, sees the economy is in trouble and a lot of discussion about taxes, but isn't all that unhappy about their own healthcare. Weighing those two things can be difficult."

"Ranking 37th -- Measuring the Performance of the U.S. Health Care System" is an article posted online by the New England Journal of Medicine. Excerpt:

Despite the claim by many in the U.S. health policy community that international comparison is not useful because of the uniqueness of the United States, the rankings have figured prominently in many arenas. It is hard to ignore that in 2006, the United States was number 1 in terms of health care spending per capita but ranked 39th for infant mortality, 43rd for adult female mortality, 42nd for adult male mortality, and 36th for life expectancy. These facts have fueled a question now being discussed in academic circles, as well as by government and the public: Why do we spend so much to get so little?

What an important question for US journalists to tackle more deeply more often.

Jim Ragsdale of the St. Paul Pioneer Press wrote a terrific column this week, "Rational health care, not rationed." It begins:

"I invented a device called Jim's Full Body Scanner. It takes up a city block, which means it cost kabillions to build and operate. But for $50,000 per scan, the Jimmer, as I call it, can give you a cell-by-cell breakdown of your bod. It can show dozens of microscopic changes, giving you a chance to take pre-emptive medical action.

Most of those scanned go right to a conveniently located miniJim Clinic for further tests, a biopsy or two, some minor surgeries or maybe even a pre-emptive transplant. I admit that it's controversial. We don't really know if some of the fixes are needed. The eggheads want long-term studies and "evidence" before deciding whether insurers should pay.

"Rationing!" I say. "They've put a bureaucrat between you and the Jimmer!"

OK, I didn't actually invent any such device. I am an aging civilian scribe whose anatomical knowledge is well below average. I imagined the "Jimmer" because it helps me understand the battle over scientific evidence and its relation to the gaping holes into which our health-care dollars disappear."

From Drew Altman, PhD, president of the Kaiser Family Foundation. Read the entire column, but here's an excerpt:

With so much of the media now configured for instant news and the relentless pursuit of controversy, stoked by spin and manufactured news by partisans on both sides, the many great journalists in the news business working hard to inform the public face a big challenge in explaining the complex issues in health reform.

MinnPost.com columnist David Brauer wonders why the Washington Post - and not a local news organization - asked tough questions about whether the Mayo Clinic is a replicable model for health care reform.

His new book, "The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care," was published this week. But this myth column was published in the Washington Post on Sunday.

Here's the tease of the five myths. Read the full article to see how he backs up each of the five.

1. It's all socialized medicine out there.

2. Overseas, care is rationed through limited choices or long lines.

3. Foreign health-care systems are inefficient, bloated bureaucracies.

4. Cost controls stifle innovation.

5. Health insurance has to be cruel.

"Smoking Memo - or Bad Journalism" - that's the title of Maggie Mahar's blog post on the alleged Obama-PhRMA deal. Excerpt:

Yesterday, it seemed that the Huffington Post's Ryan Grim had a scoop. He reported that Huffington has obtained a memo that "confirms" that the White House and the pharmaceutical lobby secretly made a deal--the deal that I wrote about a few days ago in a post titled "What Was Billy Tauzin Thinking?" According to the memo, the White House supposedly pledged to oppose any Congressional efforts to let Medicare negotiate for discounts on drugs, or to import drugs from Canada.

The memo in question turns out to be typed--and unsigned. How does the reporter know that it is authentic? "A knowledgeable health care lobbyist" told him so. According to the lobbyist the memo "was prepared by a person directly involved in the negotiations [and it] lists exactly what the White House gave up, and what it got in return.

Wait a minute. As PhRMA senior vice president Ken Johnson points out later in the story: "Anyone could have written it. Unless it comes from our board of directors, it's not worth the paper it's written on. . . ."

And who is the "knowledgeable lobbyist" who gave the memo to Huffington? His name is not disclosed.

What we have then, is a story based on what one unnamed source says--and a typed memo that probably is untraceable.

She goes on to quote me about whether this is acceptable journalism.

"Smoking Memo - or Bad Journalism" - that's the title of Maggie Mahar's blog post on the alleged Obama-PhRMA deal. Excerpt:

Yesterday, it seemed that the Huffington Post's Ryan Grim had a scoop. He reported that Huffington has obtained a memo that "confirms" that the White House and the pharmaceutical lobby secretly made a deal--the deal that I wrote about a few days ago in a post titled "What Was Billy Tauzin Thinking?" According to the memo, the White House supposedly pledged to oppose any Congressional efforts to let Medicare negotiate for discounts on drugs, or to import drugs from Canada.

The memo in question turns out to be typed--and unsigned. How does the reporter know that it is authentic? "A knowledgeable health care lobbyist" told him so. According to the lobbyist the memo "was prepared by a person directly involved in the negotiations [and it] lists exactly what the White House gave up, and what it got in return.

Wait a minute. As PhRMA senior vice president Ken Johnson points out later in the story: "Anyone could have written it. Unless it comes from our board of directors, it's not worth the paper it's written on. . . ."

And who is the "knowledgeable lobbyist" who gave the memo to Huffington? His name is not disclosed.

What we have then, is a story based on what one unnamed source says--and a typed memo that probably is untraceable.

She goes on to quote me about whether this is acceptable journalism.

In another fine example of its dedication to important health care journalism, the Milwaukee Journal-Sentinel published a piece, "Debate on MRI payments just one hurdle for reform."

Gems in this piece include:

• Information on the Access to Medical Imaging Coalition, a group backed by the major manufacturers of imaging equipment, including GE Healthcare. The paper reports: "That industry backing goes unmentioned by the innocuously named group. The Access to Medical Imaging Coalition, which includes cardiologists and radiologists, is just one of the myriad special interest groups that often oppose cuts in what Medicare pays for medical services."

• "The reality is the status quo puts a lot of money in a lot of people's pockets," said Alwyn Cassil, a spokeswoman for the Center for Studying Health System Change, a policy research organization in Washington, D.C.

  Another reality is groups such as the Access to Medical Imaging Coalition often succeed in persuading Congress to protect their interests.

Read the entire piece. It includes local angles on local industry affected and about Wisconsin legislators' activities in this area. A fine example of local journalism on a national issue.

Marketplace on NPR has begun an occasional series called "The Cure." The lead-in to the first segment said:

"Up first, the inner workings of a typical medical practice. Did you ever wonder, for instance, what all those people on the other side of the counter are actually doing? And why there are so many of them? We sent Marketplace's Tamara Keith to find out."

Keith spent the day at a doctor's practice, seeing firsthand why there were more administrative staff than health care professionals in this particular practice. They're dealing with health insurance - and different flavors of insurance from different health insurance companies. It's the American way. It's the marketplace at work that anti-health care reform forces want to preserve.

Listen to it. It's good radio journalism.

But you should also read the comments section following the text story on the Marketplace website. One guy wrote:

"I worked for Ingenix, a subsidiary of UnitedHealth group, for three years as a software developer. I worked on a crack team of Java developers who used cutting edge technology to build two huge software systems: ContractManager and iCES.

ContractManager cost $150,000 a seat. It sat in the offices of large physician practices and analyzed the doctor's rejected claims and figure out ways to bleed more money from insurance companies.

iCES sat in the office of insurance companies and analyzed claims using high technology with the intent of finding ways of paying doctors less.

Our shorthand internal way of describing what we did: "Selling guns to the Hatfields and the McCoys."

Having worked for several insurance companies, I must point out that the single payer, public option is the way to go. Right now, providers and payers are having an arms race and you and I are paying for both sides."

A physician friend of mine in Los Angeles told me her office deals with 94 different insurance plans. 94 DIFFERENT INSURANCE PLANS! And none of the people who push that paper do anything directly to benefit your health. Amazing.

Journalist Maggie Mahar blogs:

"I fear that the way the media has been reporting on reform has played a significant role in shaping the public's perception of both the president and what some like to call "ObamaCare," personalizing the issue, as if reform were merely the president's favorite hobby-horse.

Begin with coverage of health care reform. In recent weeks, Media Matters has done an excellent job of tracking how "the media continues to spread conservative misinformation on health care reform." Here are just a few examples:

 "Despite clear progress, media declare health care reform nearing "life support"

 "On health care reform, networks highlight perceived setbacks far more than progress" July 22

 "Politico ignores contradictions in calls by "moderates" for lower costs, limits on public plan" July 20

 "CBS' Smith advanced falsehood that Dems are taxing small businesses to fund health bill" July 19

 "NY Times ignores House health bill's exemption protecting small businesses"

 "Wash. Post column cites inapplicable CBO assessment to claim public plan option has 'huge cost, minor benefit'" July 07

 "CNN.com joins Republican fear-mongering about Canadian-style health care" July 07

And here I'm not even including the over-the-top distortions of the truth that have become regular fare on Fox News, and in the pages of some decidedly conservative newspapers."

There's much more on her blog.

From last week's NPR program:

A segment entitled "Blame Canada," with the Canadian Broadcasting Corporation's Maureen Taylor explaining what health care is really like north of the border. Excerpt:

MIKE PESCA: What do Canadians make of how their health care system is being portrayed in the U.S. these days?

MAUREEN TAYLOR: I think we're actually saddened that you could use something that we find works so well, the Canadian health care system, to scare Americans into voting this down and being afraid to move forward with this.

And a segment called "The language of reform" with Frank Luntz, author and Republican wordsmith, who wrote a memo called "The Language of Healthcare 2009." He says his ten rules will help Republicans stop the "Washington takeover" of health care.

Another example of fawning coverage of medical technology.

Another example of obsequious news on the DaVinci robotic surgical system, about which I've written earlier. (In fact, an earlier post just this week about the President playing with a robot at the Cleveland Clinic.)

A story in The Oklahoman reports on a university medical center's new DaVinci robotic surgical system for prostate cancer.

It failed to report on the limited evidence to support this approach. The U.S. Agency for Healthcare Research & Quality states that there hasn't been enough research to know how this approach compares with others.

It also failed to look at the apparent burgeoning medical arms race in Oklahoma City - just for prostate cancer much less anything else. One center is bragging about its latest generation robot. Another center is bragging about its even more expensive proton beam therapy.

Wouldn't that be a good story?

How local newspapers deal with issues of medical technology assessment, of community ascertainment of need, of resource allocation. of costs, of evidence is vital to public understanding of why we spend more than any other country on health care without the outcomes to show for it. Stories can educate or they can advertise. This one falls in the latter category.

(Hat tip to Craig Stoltz, from whom I borrowed the "wide-eyed new-technology-in-town" phrase, and who helped with the review of the story in question.)

Christopher Martyn, associate editor of the BMJ, writes about (subscription required for full access) the response to Atul Gawande's "The Cost Conundrum" piece in The New Yorker and wonders "whether the problems of managing the nation's health are discussed in a different way in the US. Is the level of debate on a higher plane than it is in Britain? Or are there better mechanisms for transferring what is written in medical journals into formats that are more widely available and accessible?"

Because I spend a lot of time scrutinizing US health care and health policy news, I read on. Martyn writes:

It isn't that the UK media aren't interested in medicine and health. Many newspapers have regular sections devoted to these topics. The trouble is that much of it is low grade stuff intended to pass an idle moment rather than stimulate informed debate. Why don't the editors of serious dailies and weeklies emulate the New Yorker and commission some pieces tackling healthcare topics that matter? Instead of trivia about the illnesses of celebrities or whether feeding fish to your children makes them more intelligent, couldn't we have discussions about whether the National Institute for Health and Clinical Excellence is right to consider valuing quality adjusted life years (QALYs) differently at the end of life? Or why the (UK's National Health Service) finds it so hard to deliver health care to those who need it most? Or what we actually mean when we talk about inequalities in health?

It's always convenient to blame the media, but part of the fault may lie closer to home. Getting mainstream media coverage has become an important measure of success not only for researchers but for the institutions they work in, the bodies that fund them, and even medical journals. Courting media attention by issuing a press release when a paper is published substantially increases the chances of getting the findings on television or into the newspapers. But it also influences the way they are reported. Journalists working to a tight copy deadline don't have the time or ability to make their own critical appraisal of the research. Instead, they rely on the content of the press release, supplemented perhaps by a telephone conversation with the researcher. You might think the claims made by these press releases would be measured and unexaggerated. After all, even if they're written by university or funding agency press offices, they're presumably checked by the people who actually did the research. But you'd be wrong. A recent evaluation of press releases from academic centres found that a large percentage overstated the importance of the findings and failed to mention aspects of the study that limited the clinical relevance of the results.

If you agree that raising the standard of reporting of medical research and healthcare issues in the mainstream media would be worthwhile, issuing fewer and more accurate press releases might be a good place to start.

With all of those aging prostates on Capitol Hill, one wonders how much money Washington, DC urologists make off of legislators' walnut-sized glands.

Here are two examples of the kind of public discussion through journalism that we need more often - and both focus on prostates.

David Leonhardt discusses prostate cancer as a litmus test for health care reform. Why prostate cancer? He explains:

Some doctors swear by one treatment, others by another. But no one really knows which is best. Rigorous research has been scant. Above all, no serious study has found that the high-technology treatments do better at keeping men healthy and alive. Most die of something else before prostate cancer becomes a problem.

"No therapy has been shown superior to another," an analysis by the RAND Corporation found. Dr. Michael Rawlins, the chairman of a British medical research institute, told me, "We're not sure how good any of these treatments are." When I asked Dr. Daniella Perlroth of Stanford University, who has studied the data, what she would recommend to a family member, she paused. Then she said, "Watchful waiting."

But if the treatments have roughly similar benefits, they have very different prices. Watchful waiting costs just a few thousand dollars, in follow-up doctor visits and tests. Surgery to remove the prostate gland costs about $23,000. A targeted form of radiation, known as I.M.R.T., runs $50,000. Proton radiation therapy often exceeds $100,000.

And in our current fee-for-service medical system -- in which doctors and hospitals are paid for how much care they provide, rather than how well they care for their patients -- you can probably guess which treatments are becoming more popular: the ones that cost a lot of money.

Use of I.M.R.T. rose tenfold from 2002 to 2006, according to unpublished RAND data. A new proton treatment center will open Wednesday in Oklahoma City, and others are being planned in Chicago, South Florida and elsewhere. The country is paying at least several billion more dollars for prostate treatment than is medically justified -- and the bill is rising rapidly.

You may never see this bill, but you're paying it. It has raised your health insurance premiums and left your employer with less money to give you a decent raise. The cost of prostate cancer care is one small reason that some companies have stopped offering health insurance. It is also one reason that medical costs are on a pace to make the federal government insolvent.

Meantime on MinnPost.com, Susan Perry writes about more doubts about prostate cancer screening:

On Father's Day last month, Sen. John Kerry, D-Mass., and radio shock jock Don Imus co-authored an op-ed for the Boston Globe in which they argued that men needed to be sure they received regular preventive screening check-ups for prostate cancer. Both men are prostate cancer survivors.

"Screening for prostate cancer is the only option," they wrote.

But therein lies a big, big problem -- and yet another medical controversy. Just a few days after that op-ed ran, a review article in the medical journal CA: A Cancer Journal for Clinicians reported that the PSA blood test, routinely used to screen for prostate cancer, saves few lives, wastes money and often leads to risky and unnecessary treatments.

An editorial that accompanied the review noted that not a single well-designed clinical trial has yet to show that PSA screening reduces the death risk from prostate cancer.

However, if you don't want to be discouraged about engaging the public in a discussion of the role of evidence in health care refom, don't read the comments attached to either piece.

The Wall Street Journal added to the discussion about cost-effectiveness of cancer drugs reflecting on a commentary in the Journal of the National Cancer Institute estimating that "it would cost $440 billion to extend life by one year for the 550,000 Americans who die annually of cancer."

Important topic. I'm glad the WSJ addressed it.

But one line bothered me. It read:

"Some countries, like the United Kingdom, agree to pay for expensive drugs only if they meet a certain threshold of efficacy, but no such rationing exists in the U.S."

A news story that comes right out and labels a demand for proof of efficacy as rationing?

A semantics purist may say that the term applies in this discussion - like restricting or rationing consumption of meat or electricity during war.

But given that any newsroom must realize how the term is used as a heavy-handed piece of rhetoric by those who oppose evidence-based medicine and who oppose health care reform that calls for such evidence, this seems like editorializing.

Good story - but that one word in that one sentence left a bad taste for me. Semantics, word choice and framing matter if you care about public understanding of complex health policy issues.

Despite my red marks on that one section, read the rest of the article (if it's still available online), which was important enough to be on page one of at least the D section of the printed WSJ, not way back on D4.

That quote comes from a Minnesota physician in a Pioneer Press article that includes many good elements:

• Info on disparities in Medicare spending;


• Dartmouth Atlas data and graphic;


• Local angle on Atul Gawande's New Yorker piece .

Kudos to reporter Jeremy Olson.

I'm honored to be included in a list of commenters recruited by the Kaiser Health News Service to react to Atul Gawande's New Yorker piece on "The Cost Conundrum."

KHN writes:

"The ... article is now being called one of the most influential health care stories in recent memory. The New York Times reported that President Obama made it required reading for his staff and cited it at a meeting with Democratic senators last week. His budget chief, Peter Orszag, has written two blog posts about the article. Health and Human Services Secretary Kathleen Sebelius referred to it in a speech at the John F. Kennedy School of Government last week. Lawmakers on the Hill also are discussing it. Congressman Jim Cooper, D-Tenn., for instance, says the article has "shifted perceptions on the health care industry."

Then they asked the following to comment - an interesting range of perspectives:

• Robert Blendon, Professor of Health Policy and Political Analysis, Harvard School of Public Health and John F. Kennedy School of Government

• Greg Scandlen, Senior Fellow, Heartland Institute

• Joseph W. Stubbs, President, American College of Physicians

• E. Linda Villarreal, Past President of the Hidalgo-Starr County Medical Society, Internist in Edinburg, Texas

• and me.

By the way, if you want to learn about health policy and if you haven't been following the recently-launched Kaiser Health News Service, you should be.